How to Identify Data in Nursing Field

Topics: Nursing, Nursing care plan, Health care Pages: 2 (587 words) Published: April 18, 2013
1. The nursing process is the core for the nursing care plan and enables one to think like a nurse. The nursing process is important as it is a systematic problem solving approach which involves the partnership with both the patient and their family. It serves as an important tool to improve practice, quality care and promote good health. The nursing process has four phases include assessment, diagnosis ,planning, implementing, evaluation. 2. One of the components of assessment would be the Chief complaint. the chief complaint is a brief statement of whatever is troubling the patient and the duration of time the problem has existed. The chief complaint is the signs and symptoms causing the patient to seek medical attention. Generally, it is the answer to the question, "What brought you into the hospital (or clinic) today?" If a well person is seeking a routine physical, there is no actual chief complaint Another component of assessment is the past medical history. This provides background for understanding the patient as a whole and his present illness. It includes childhood illnesses, immunizations, allergies, hospitalizations and serious illnesses, accidents and injuries, medications, and habits. Family health history. This enhances your understanding of the environment in which the patient lives. Obtaining this information identifies genetic problems, communicable diseases, environmental problems, and interpersonal relationships. Specific inquiry should be made regarding the general state of health of parents, grandparents, siblings, spouse, and children. Record if the patient is adopted and has no access to his biological family's history. 3.In the health history,during this assessment you must interview the patient to obtain a history so that the nursing care plan may be patterned to meet the patient's individual needs. The history should clearly identify the patient's strengths and weaknesses, health risks such as hereditary and environmental factors,...
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